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16 HORTON ST - BUILDING INSPECTION (4) The Commonwealth of MaGIs, etts Department of Public Saf �' �'„/ \les.ad+usvlls tilalr Building Ludr 179U C\IdrUun �[/. • , - - City of Salem n,f BuildingPermit Application for an Buildingother 2• mil Dwellin 000///NN 1 fhn 1a-cnun For Official Ule Onlvl ( Building Perinu Number Dale Applied: Budding I xf cta SECTION 1: LOCATION(Please indicate Black a and Lot a for locations for%A4 + jyresi2,. not available) �� r�`•1� S-F �a�O.tM 44k j \o. and Street 01% /Town Zip Code Name t Budding(it apphcable) SECTION 2:PROPOSED WORK If New,Construction check here❑or check all that apply in the two rows below '. J l ""----- --"- -E"clsting Building-- --Rrpair-O —=Adaiilion-❑ -Demulilisrst-❑-(J'aeasr-fill-out-anil-.ubmil-Aypa»dix-1-)- , Change of Use ❑ Change of Occupancy ❑ Uther ❑ Specify: Are building plans and/or construction documents being supplied as pan of this permit applica tiun? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required?" Yes ❑ No ❑ Brief Description of Proposed Work: z j SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑ Existing Use Group(s): Proposed Ur Group(s): y Existing Hazvd Index 730 CMR.34; Proposed Hazard Index 780 CMR 34: SECTION 4:BUILDING HEIGHT AND AREA Existing Propused• No.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(-scl.ft.).md Total Height(ft.) . . SECI70N 5:USE GROUP(Check as app licable) A: Assembly A-l.❑ A-2r ❑ A-2nc❑ A-3 ❑ A4 O A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-I ❑ F2 O H: Hiera Hazard H-I ❑ H•2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional 1-1 ❑ 1-2 ❑ 1.3❑ 1-4❑ M: Mntile❑ R: Residential R-10 R-2 ❑ R-3❑ R-4❑ S: Storage S-1 ❑ 5-2 ❑ U: Utility O Special Use❑and please describe below: 5peaal Use: - SECTION 6:.CONSTRUCTION TYPE(Check as applicable) IA IB ❑ IIA ❑ IIB ❑ JIIA ❑ 11180 IV CI VA ❑ VB ❑ SECTION 7:SITE INFORMATION frefer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: french Permit: ' Debris Rrmovab Public❑ 1.heck duulsrdr Il..nl ZVIN•❑ In.hcale munrcip.J❑ A trench wdl nut be Licrn.rd D,spo...[?err❑ I'r'1\'aIV❑ „r inyla•nhly Zonv:_ ,r on.dr•cdrm❑ rcqurrcd ❑ur trench ,.r.l•cu K. I•ermn n cnclo'e l ❑ _ i Railroad right-ofweay: Hazards to Air.Vavigation: ....... -- \ol \/•I•h..d•la•❑ 1-11ru.lut,adhin eoporl al`)`n adi.,n•.r' Llhcn ,cs ic,. cnn1•Ioh J' " 1 . „•rnl b,lluddc "I.,.cd❑ � . lr.Q ,,r\u❑ low❑ \ , O .._� SECno.N A:CONTENT OF CF.RTIFICA TE OF OCCUPANCY I JJi,nt. r ( .0, L-c l.,. a/,,.r (.I`c -I1 .-n.uu.non .___ l,ccu Lent 1.0.1,1 /cr 11. Ir.•,—rhr l`m I,L ,a..,num.m �pnnklcr�l.irm' `)`rcral�lipuleunn. � 1�1 (_ T SECTION 9-. PROPERTY OWNER AUTHORIZATION N.i mr.n td Add rv,,.1 11r, pvrlF llce ner t \. it j4 + \.unr IPr; 1 No—Ind}level (lh, Gn I'n-perlc(tssnrr( , AO la ur alaon - Lf(/QU idle relephone No. (bu,mrse) relephone No. (cell) r mail .plJn•.. It.) + +hi.;ble,the +rop r1% owner herebs• authorizes Name mrvv1Addrens Cih'/iown ?late Gp w acl tm the +n�•.•etc on ner'.brhelf, in a mailers ra•Iath a to work authorized by tht,buddm • permit a + ilt%mion. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) (II building is Its than Ii,UUcu.It.of ends csl.+acc and/or nol under C+mstnichon Canlrul then check here O and 4,,v loin Ill 1) 10.1 Re istered Professional Responsible for Construction Control Rehrira rep on o. a-mat a es egistralionNumber Street Address City/To n State Lip Discipline xpiraoon Dale 10.2 General Contracto S � Comp y N. e: .Namead Person Usponsiblir for mtructiun License o. and Type A licable tr� dress `' City/'Town State Zip Telephone N,.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COWENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) A Workers'Cumpehsation Insurance-Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes O No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1. Building § Building Permit Fee=Total Construction Cost x _(Insert here 2. Electrical S appropriate municipal factor)_§ 3. Plumbing $ N. Mechanical (HVAQ S Note:Minimum fee=S (contact municipality) 5. Mechanical (Olhrr) § ` Enclose check payable to _ 6. TnLil Cost $ L (contact munici alit )and write check number here SECTION 13:SIGNATURE OF BUILDING PERMITAPPLICANT By vnlering my name below,I hrrebv attest under the pains and penalties of pequry that all of the nf, mat,,n o mt ned m this applic.ahnn is true and accurate to the be,l of my knowledgeand under,Lndmti. I'Iv.iv print and •ign n.;mr fide -__— — rrlcph,mr \ � Uatr �b.el \+Lira•.. —_ i Numopal inspector to till out this section upon application approval: . mr I li;r r. -- !!,- 3}r{s�r�.mctt! of Public u=.c �afci} 1 ' Bo lyd u, t3u0ltn 32c1u taus, and �rindartV. 0 License: CS 104865 CLINTON GALVINj 102 DELMONT AVE APT 2 LOWELL,MA01852 Expnauon: 711I2014 ( nl1p111�*iu1,P` . n •✓/zo {irnr>oneareuiv�f� cj/'' !l"•.�t�`�li'� Ogee of Consnmer Affays&Bds'ioess Aegutatiou 2+ ! C a �iz HOME IMPROVEMENT CONTRACTOR §t om Registration: 169535 TYPs q: Private Corporatioi Expiration: 7/1@U73 RYAA'AND SON ROOFING INC. .. .CLINTON GALVIN. 93 NEW SALEM STD:. -G---+�� !WAKEFIELD.MA 01880- Undersecretary The Commonwealth oj'Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(BusinesslOrganimtion/Individual): t{ Address: a. ply{ n City/State/Zip: D f 6�V Phone#: re. ou an employer?Check the appropriate box: Type of project(required): I. I am a employer with.___ 4- El am a general contractor and 1 6. El New construction employees(full and/or part-lime).• have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance, q. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL I l.❑Plumbing repairs or additions myself[No workers'comp. c. 152,§1(4),and we have no I2.❑Roof repairs insurance required.]t employees.(No workers' r,( 13. Other 'S comp. insurance required.] ' a Any applicant that checks bon pi most also fill out ale section below slowing their workers compensation policy inlbsmation. t Homeowner who submit this affidavit indicating they are doing all work and then hire outside cormadors must submit a new affidavit indicating such. tContractors that check this box must attached an additional shut stowing the name of the,subcontmctors and their workers'romp.policy infarmatioq.. I am an employer that is providing workers'compensation Insurance for my employees. Below is the policy andjob.site ` information. Insurance Company Name:,__ , ,,�.,--/e`____ Policy#or Self-ins.Lic.#4 S 41k ,� '/ � Expiration Date:y$/`49 �—�-- Job Site Address: 1140 t2.f7n t 94 _____ City/State/Zip:__ Attach a copy of the workers'compensation policy declaration page(showing the policy number expiration pir do date). Failure to secure coverage as required under Section 25A of MGL.c. 152 can lead to the imposition of criminal penalties of a tine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a S'fOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer/hfy�'f der p and p 'tie rjury that the information provided above is true and correct. Signature: _ Date_Iv��, Phone#: / 7� OffWat use only. Do not write in this area,to be completed by city or town official. City or Town: Permil/License# Issuing Authority(circle arse): 1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: ' a UP iu: 5W 4cc�rrc� CERTIFICATE OF LIABILITY INSURANCE DAT09126DIPYYYI 111 `'PHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES 1 BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. I IMPORTANT! If the certificate holder is an ADDITIONAL INSURED,the policy(ios) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,.certain policies may require an endorsement, A statement on this certificate does not center rights to the certificate holder in lieu of such ondomement(s). PRODuCFR 978-996-6896 N°M FacT 127 a ay Garden Street U it 18 s.LL.0 1"Y" FAX '- ;2l Gartlan Street Unit 18 978-998 6897 IA/G No PAX (Art. W1 10eyer .MA01915 EMne ry. ADORFs± (Sharlene Hilda Wulleman PRODUCER cusroaER RYANSON _ `VSORERIS)AFFORDING COVERAGE NAICa INSURLD Ryan&Son Roofing,Inc esuueR A;Ace American Insurance Co 93 New Salem St IN-11-11,H Wakefield,MA 01880 INFIIRER C 1 ' INS"tlkfili(J INSIIR",L COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURAN E 1IS'1'EU FTFLON HAVE KEEN ISSUECt TO 114E INSURED NAMED ABOVE FOR TFIE POLICY PERIOD INCHCATED. NOTWITHSTANDING ANY Rl OUIREMFNT TERM OR f,.ONDTTION OF ANY pONT'RA(,T OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS OFRTIIHCATF MAY 9E ISSUF,D OR MAY PFi RTA)N. 1'HY INSURANCE. I0 FORDED BY THE '01ACIES DESCRIBED HEROIN IS SUS.IFC;T TO ALL THE TERMS iXCLll ilONS AND CgNI)ITIONS JF SUCH i'OI_ICIF'.S LIMIT$,SHOWN MAY HAVE HI:iI-N W DACE)BY PAID CLAIMS. I.3R - A001.�S11RR POI It Y Lrf POLICY E%P - TR RP(Or INSORAN11 I(11,1('Y hllMet R MM)ll(UYYYY MMfDD1YYYV ,M T5 GENERAL 1-MRIUTV (A0I(I'(UPALNR,F CG AMF( d ol0a[✓ .f? AMa f Y RTNT .. CnfiR,YiNRI A;,(eI:..IP, af,'. � Y 4 f I .•e8 g',MIr GS S .f M ___ s Al1TOORI1 F11PRIUiY .. _.—.... � ....._..... _ _ ...__. .._......:_ ____ M 11J1 yN9:.i IF'"' 1 fy,3214 I I F':o +-: 4H1 9C5 Ye1R t :p,5 I N(!f _fAMn(jE 1 C11 S UMeHBLLA UAd " Lf I:;DRRF"- e%OFSS uAe - I WONNERSCOMPFNSATION —.— .. __—__. ANOT-MPIOYCRS IASIUTY YIN IA PY M �; X E> A n <o e �R 1 e 1 - NIA 6S62UB-4571P66-9-11 03H601 03116M2 1 t ( ,tits'(•( S 1.000,00 .!'OERMFM xl-.,.IqI U> IMen,w(or01 him Nx) I S ON G;.rMF �I t'.'S 1,000,001 If yac,tlts ba wVCr FUI. + IMI:'':S 1.000,00 ..... . .---- ._. ______ ___'EESC.RIPTION O(OPf RAt pNSl )rAIONSeVl:l1:(.1(l(Ah1:,.It Al ll Ell Ot.ArRl t,t,np R -' i—� --- `�' ;Evidence of Insurance r _._..._.._-_.-__-. ._.___—___.—_.._..._....TIFICATE HOLDER CANCELLATION Etidd�y� p� Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ence of Insurance THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. for bidding purposes only OPol1'JiekVHEtifN(g 71 VF. ©1988-2009 ACORD CORPORATION. All rights reserved ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD PDF Created With OfFactory trial version www.odffactory corn ' s Proposal 93 Now Salem Street, Wakefield MA 01880 TeL ri 17-571-9056 Emell:RyanMdSonS(iilMaann www.RvanAndSonRoofing.com Submitted To: lob location: Shelly Barling 16 Horton St: Salem,•MA n 16 Horton St Mar �: 978-210-4494 Salem,MA on Emal1:' nuchellebarling@nnsn.com Proposal date:October 24,2011 We are pleased to hereby submit this proposal to furnish materials and labor,completely In accordance with the below specifications: (Additional charges may applyJisr any changes not.i ieluded below in proposal either by request o/owner, or{(Ryan and Son Rogfmgfindc unforeseen eirruindances that will filer t the performance,quality or hnegrrry oJ'lhis.tub). In Ibe even/lrgal«cllnn is inhen to enforce tiny provision n/Y/v:c agrernaen/, the pr<vailing pony shall be entitled tb till ztr rena urvcrble curly. inclndrng reasonable zn-house or outside oidurney'e debris in attic. fees. Not responsible for THISPROPOSUISTO: Strip roof to bare wood and re-shingle:Includes all sections of roof except top addition WIII Install rubber roofing system to front poreb and remove satellite dishes • Strip existing shingles down to bare wood • Check for rotted wood and replace as needed • Nail down any(dose wood • Install ice&water shield to first.6',which is 2-rows and in all valleys • Install 301b felt paper to remainder of roof • Install all new 8"white drip edge on perimeter and step(lashing,where needed • Install GA Lifetime/30-year architectural shingles in color of your choice • Install ridge vent and hip&ridge cap,to match • Properly flash any protrusions and all new pipe Flanges,ifany on roof • Will repair gutters as needed Clean Up: • Will cover area with tarps to minimize debris • Remove debris related fir work • NOTL.: Please cover any belongings in the attic,as they will get dusty,ifapplicuble Payment Terms made asIallows: (This includes labor, dunip& materials) Strip a shingle roof price: $4,350 Kindly remit payment to Total cost:l(fno changes] $4,350 "Peter Ryan° 19 Payment due upon signing: S1,500 Thank you! Balance due upon completion 9 RespectiBIIV Submitted by: 1 - Accepted by: All work is 100"/o guaranteed for 10-years tin all ci aftsnnntihtp:,?Xtl aolher warrantees arc through the manufacturer.All wa r races will he null vo' if Job a not paid in full.'Phank you for Iettin�,us serve you!!! Ryan And Son Roofing, Inc.is fully licensed(N 15 797)& insured. i CITY OF SALEM, Akss.1CfjL:SETTS r 9L't1J7LVG DEP.IRTIFNT 110 W.Q.4LVGTON STMU, JiO FLOOR I'M (978) 745-9595 K11®ER1EY DRLSCOLL F,IX(978) 740.984 .tiL1YOR Nomu ST.PMUA DIRECTOR OF Pt;9LlC P40P8RTy/8CILpLNG CON01ISS10NEX Construction Debris Disposal Affidavit (required for all demolition and rcnavation work) In accordance with the sixth edition of the State Building Cade, 780 CMR section I 11,s Debris, and the provisions of MOL c 40, S 54; Building Permit N i S I SOA. s issued with the condition that the debris resulting from (his work shall be disposed of in a properly licensed waste disposal facility as defincd by MOL c 111, The debris will be transported by: n_ (name of hauler) 'Y1. The debris will be disposed of in : Ric 4 c 104 (name of olily) Oman Gull /�d �o,�bLf��r �J4 (iddrera or r3cdny) + tln+n+rc ofpermrt ipplrunt 0111.al yam.